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Trivandrum Heart Failure Registry
Harikrishnan.S MD, DM, FRCP, FACC
Additional Professor
Sree Chitra Tirunal Institute for Medical Sciences and Technology,
Trivandrum, India.
Heart Failure
• No data on incidence and prevalence from India.
• No data on the profile of HF and the practice patterns.
• Is likely to be a major disease burden in India.
TRIVANDRUM HEART FAILURE REGISTRY
• First heart failure registry in India.
• Supported by ICMR – Indian Council for Medical Research.
• Covered all hospitals in an urban area in South India - Trivandrum
and a nearby rural area- 25 Kms from the city.
Athiyannoor
Trivandrum HF registry
• Urban Area –
Tvm City corporation - Area 141 Sq Km,
7,45,000 Population).
• Rural Area –
Athiyannoor block panchayat (Area 42 Sq Km,
Population 4.5 Lakhs.)
13 Hospitals
5 Hospitals
Hospitals – 13 Urban, 5 rural
Mix of hospitals..
Public – Private
Cardiologist – Non-cardiologist
Interventional facilities – No interventional facilities
Academic - Non-academic
Tvm HF Registry –
Investigators meet
• Investigators meet – We had in-depth discussion about
the proforma, data collection techniques.
• The nurse-co-ordinators also participated, they were
trained.
Tvm HF Registry – Data collection techniques
• The cardiologist will identify all HF admissions – ESC
2012 Criteria.
• The nurse / research co-ordinators who were trained,
enter the data in the paper proforma.
• The study co-ordinators – Two research nurses and two
social workers ( stationed at SCTIMST), physically visit
each hospital twice a week in bikes and collect data.
Tvm HF Registry
• Started on Jan 1st 2013 – Ended 31st December 2013
• One year.
• All patients with Heart Failure.
• Readmissions of the same pt. were not counted.
Tvm HF Registry –
Preliminary data analysis
• 1232 patients admitted
• 27 readmitted in another hospital were excluded.
• 1205 cases – 0ne year period
• 833 (69%) males, 372 (31%) females.
69%
31%
TVM
Male
Female 48%
52%
ADHERE (US)
ADHERE* OPTIMIZE-
HF**
ESC HF
Pilot***
ATTEND**
**
THFR
N
105388
48612
1892
4804
1205
Country
US
US
Europe
Japan
India
Females 52% 52% 37% 42% 31%
*Fonarow GC et al. Arch Intern Med 2005;165:1469–1477.
** Abraham WT, OPTIMIZE-HF. J Am Coll Cardiol 2008;52:347–356.
*** Maggioni AP, (ESC-HF Pilot). Eur J Heart Failure 2010;12:1076–1084.
**** Sato et al. ATTEND Registry - Circ J 2013; 77: 944 – 951
% Females
% Sex wise
Age distribution
ADHERE OPTIMIZE-
HF
ESC HF Pilot ATTEND THFR
N
105388
48612
1892
4804
1205
Country
US
US
Europe
Japan
India
72.4+14 73+14 70+13 73 61.2 +/- 13.7 Yrs
Age distribution
*Fonarow GC et al. Arch Intern Med 2005;165:1469–1477.
** Abraham WT, OPTIMIZE-HF. J Am Coll Cardiol 2008;52:347–356.
*** Maggioni AP, (ESC-HF Pilot). Eur J Heart Failure 2010;12:1076–1084.
**** Sato et al. ATTEND Registry - Circ J 2013; 77: 944 – 951
TVM Registry - 2013 US DATA - 2010
Japanese (ATTEND) Registry
> 80 yrs – 36.5% *Fonarow GC et al. Arch Intern Med 2005;165:1469–1477.
** Sato et al. ATTEND Registry - Circ J 2013; 77: 944 – 951
ISCHEMIC CARDIOMYOPATHY 36%
ACS 35%
DCM 13%
RHD 8%
HFpEF(>45%) 25%
MISC. 5%
AETIOLOGY OF HEART FAILURE - TVM HF Reg.
NON-RHD VALVE 2.5%
RIGHT HEART FAILURE 1.5%
Congenital HD 1.3%
PERI-PARTUM CMP 0.25%
AETIOLOGY OF HEART FAILURE - TVM HF Reg.
Miscellaneous
*Krum H, Abraham WT. Heart failure. Lancet 2009;373:941–55.
**Sato et al. ATTEND Registry Circ J 2013; 77: 944 – 951
WESTERN*
ATTEND –
JAPANESE**
INDIA - THFR
ISCHEMIC 63% 31 71%
DCM 17% 13 13%
Non RHD Valve 5% 19 2.5%
RHD - 8%
HYPERTENSION 4% 17 2%
AETIOLOGY OF HEART FAILURE - COMPARISON
ADHERE OPTIMIZ
E-HF
ESC HF Pilot ATTEND THFR
N
105388
48612
1892
4804
1205
Country
US
US
Europe
Japan
India
Hypertension 73 71 62 72 58
Diabetes 44 42 35 31 55
Smoking - - - 43 41
(M=69%)
CKD 30 20 26 - 18
RISK FACTORS (%) - COMPARISON
*Fonarow GC et al. Arch Intern Med 2005;165:1469–1477.
** Abraham WT, OPTIMIZE-HF. J Am Coll Cardiol 2008;52:347–356.
*** Maggioni AP, (ESC-HF Pilot). Eur J Heart Failure 2010;12:1076–1084.
**** Sato et al. ATTEND Registry - Circ J 2013; 77: 944 – 951
ADHERE OPTIMIZE-
HF
ESC HF Pilot ATTEND THFR
N
105388
48612
1892
4804
1205
Country
US
US
Europe
Japan
India
Atrial
Fibrillation /
Flutter
31 31 44 35 16
ATRIAL FIBRILLATION/FLUTTER (%)
*Fonarow GC et al. Arch Intern Med 2005;165:1469–1477.
** Abraham WT, OPTIMIZE-HF. J Am Coll Cardiol 2008;52:347–356.
*** Maggioni AP, (ESC-HF Pilot). Eur J Heart Failure 2010;12:1076–1084.
**** Sato et al. ATTEND Registry - Circ J 2013; 77: 944 – 951
Duration of therapy and mortality
• The mean duration of hospitalization was 8 +/- 6.2 days.
• The total in-hospital mortality was 8.4% (102 patients).
• Females had higher mortality 9.9 % Vs 7.4 in males
(P =NS)
ADHERE OPTIMIZE-
HF
ESC HF Pilot THFR
N
105388
48612
1892
1205
Country
US
US
Europe
India
LENGTH
OF HOSP
STAY
4.3 5.3 - 8
*Fonarow GC et al. Arch Intern Med 2005;165:1469–1477.
** Abraham WT, OPTIMIZE-HF. J Am Coll Cardiol 2008;52:347–356.
*** Maggioni AP, (ESC-HF Pilot). Eur J Heart Failure 2010;12:1076–1084.
**** Sato et al. ATTEND Registry - Circ J 2013; 77: 944 – 951
DURATION OF HOSPITAL STAY (DAYS)
ADHERE OPTIMIZE-
HF
ESC HF Pilot ATTEND THFR
N
105388
48612
1892
4804
1205
Country
US
US
Europe
Japan
India
In Hospital
Mortality
4.0 3.8 3.8 6.4 8.4
IN-HOSPITAL MORTALITY
*Fonarow GC et al. Arch Intern Med 2005;165:1469–1477.
** Abraham WT, OPTIMIZE-HF. J Am Coll Cardiol 2008;52:347–356.
*** Maggioni AP, (ESC-HF Pilot). Eur J Heart Failure 2010;12:1076–1084.
**** Sato et al. ATTEND Registry - Circ J 2013; 77: 944 – 951
Tvm HF Registry – Drug therapy
DRUGS AT
DISCHARGE
OPTIMAL TREATMENT
ACEI/ARB + BB + ALDOSTERONE BLOCKER
Only 25% (95% CI: 21.8-27.4) of the patients with
LV systolic dysfunction received optimal treatment at
discharge
Optimal treatment and outcomes.
ACEI/ARB + Beta Blockers + Aldosterone blockers
3 Month follow-up data
The 90-day follow-up rate was 97% (35 patients lost to follow-up)
116 patients died during the 90 day follow-up period.(9.6%).
Cumulative mortality at 90 days was 18.6%
3 Month follow-up data – Cause of death
Pump failure – 43 /116
SCD - 72 /116
Hepatic encephalopathy – 1 /116
One year follow-up data.
1170 patients followed-up out of 1205 patients
(97% follow-up)
265 patients died on follow-up after discharge.
Total mortality at 1 year – 31.7%
Chen J JAMA. 2011 Oct 19;306(15):1669-78
US National Claims History files from the Centers for
Medicare & Medicaid Services (CMS)
One year follow-up data.
US National data, 1999 – 2008
The unadjusted 1-year mortality rate for HF hospitalization was.
31.7% in 1999 and 32.0% in 2008*
In hospital – 2 - 17%
One year -- 17 – 45%
One year follow-up data
EUROPE
Cohort.
We are now converting this registry to a cohort.
Trivandrum heart failure cohort.
Tvm HF Registry –
Compared to data from the west, Indian patients are
Younger by 10 yrs; have male predominance,
More have CAD and
In-hospital stay was longer and
In – hospital mortality was higher.
One year mortality was 31.7% - similar to data from the US ad Europe
Usage of evidenced based therapy was not very different from the west
but sub-optimal.
Trivandrum HF Registry
• Data regarding HF is different from West.
• This has implications at the physician level and also at
policy levels.
• Quality improvement programs may help to improve the
outcomes.
Thank you
Type of HF
GENDER
Total
M F
ACUTE DENOVO HF 335 144 479 (40%)
ACUTE ON CHRONIC
HF 499 227 726 (60%)
Total 834 371 1205
ACUTE DE-NOVO HF
Italian Registry (IN-CHF) – 43 %
Japanese (ATTEND) – 64%
*Sato et al. ATTEND Registry - Circ J 2013; 77: 944 – 951
**Oliva et al. IN CHF Registry European Journal of Heart Failure (2012) 14, 1208–1217
PATTERN OF HF ADMISSIONS
Type of HF
GENDER
Total
M F
ACUTE DENOVO HF 335 144 479 (40%)
ACUTE ON CHRONIC
HF 499 227 726 (60%)
Total 834 371 1205
ACUTE DE-NOVO HF
Italian Registry (IN-CHF) – 43 %
Japanese (ATTEND) – 64%
*Sato et al. ATTEND Registry - Circ J 2013; 77: 944 – 951
**Oliva et al. IN CHF Registry European Journal of Heart Failure (2012) 14, 1208–1217
PATTERN OF HF ADMISSIONS
In hospital mortality
• The total in-hospital mortality was 8.4% (102 patients).
• Females had higher mortality 9.9 % Vs 7.4 in males
3 Month follow-up data
The 90-day follow-up rate was 97% (35 patients lost to follow-up)
116 patients died during the 90 day follow-up period.(9.6%)
Cumulative mortality at 90 days was 18%
Pump failure – 43 /116
SCD - 72 /116
Hepatic encephalopathy – 1/116
34/292 F – 11.6%
82/660 M – 12.4%
ADHERE OPTIMIZ
E-HF
ESC HF Pilot ATTEND THFR
N
105388
48612
1892
4804
1205
Country
US
US
Europe
Japan
India
Hypertension 73 71 62 72 58
Diabetes 44 42 35 31 55
Smoking - - - 43 41
(M=69%)
CKD 30 20 26 - 18
RISK FACTORS (%) - COMPARISON
*Fonarow GC et al. Arch Intern Med 2005;165:1469–1477.
** Abraham WT, OPTIMIZE-HF. J Am Coll Cardiol 2008;52:347–356.
*** Maggioni AP, (ESC-HF Pilot). Eur J Heart Failure 2010;12:1076–1084.
**** Sato et al. ATTEND Registry - Circ J 2013; 77: 944 – 951
Trivandrum HF Registry
• All cardiologists, physicians in that area contacted and
invited, good response.
• Discussions with cardiologists and physicians from all
hospitals in Trivandrum urban and Athiyannoor block
and its drainage area.
• Proforma was drafted and circulated.
IN HOSPITAL THERAPY
• Inotropic support – 11% (Dobutamine, Dopamine, NE, Milrinone).
• Diuretic administration – 94%
• Vasodilators ( Nitrates, Hydralazine) – 33%
ADHERE OPTIMIZE-
HF
ESC HF Pilot ATTEND THFR
N
105388
48612
1892
4804
1205
Country
US
US
Europe
Japan
India
Atrial
Fibrillation /
Flutter
31 31 44 35 16
ATRIAL FIBRILLATION/FLUTTER (%)
*Fonarow GC et al. Arch Intern Med 2005;165:1469–1477.
** Abraham WT, OPTIMIZE-HF. J Am Coll Cardiol 2008;52:347–356.
*** Maggioni AP, (ESC-HF Pilot). Eur J Heart Failure 2010;12:1076–1084.
**** Sato et al. ATTEND Registry - Circ J 2013; 77: 944 – 951
ADHERE OPTIMIZE-
HF
ESC HF Pilot ATTEND THFR
N
105388
48612
1892
4804
1205
Country
US
US
Europe
Japan
India
ISCHEMIC
ETIOLOGY
65 46 50 31 71
ISCHEMIC AETIOLOGY IN THE REGISTRY
*Fonarow GC et al. Arch Intern Med 2005;165:1469–1477.
** Abraham WT, OPTIMIZE-HF. J Am Coll Cardiol 2008;52:347–356.
*** Maggioni AP, (ESC-HF Pilot). Eur J Heart Failure 2010;12:1076–1084.
**** Sato et al. ATTEND Registry - Circ J 2013; 77: 944 – 951
INVESTIGATIONS
Echocardiography was available in 97% of the patients.
(Mandatory)
BNP was available 363 patients
Average value at admission – 6214.
S.Creatinine Level : 1.47 mg%
Hemoglobin Level. 12.03 gm%
Type of HF
GENDER
Total
M F
ACUTE DENOVO HF 335 144 479 (40%)
ACUTE ON CHRONIC
HF 499 227 726 (60%)
Total 834 371 1205
ACUTE DE-NOVO HF
Italian Registry (IN-CHF) – 43 %
Japanese (ATTEND) – 64%
*Sato et al. ATTEND Registry - Circ J 2013; 77: 944 – 951
**Oliva et al. IN CHF Registry European Journal of Heart Failure (2012) 14, 1208–1217
PATTERN OF HF ADMISSIONS
• The proforma will be checked for omissions/ errors there
itself and missing data collected.
• The data will be entered into MS Excel sheet.
• At the end of the month, the PI / Co-PI will check all
proformas for errors, mis-diagnosis etc.
Tvm HF Registry – Data collection techniques
RHYTHM Total
SR 80%
AFIB 15%
AFL 0.9%
OTHERS (eg.IVCD) 4%
LBBB 9%
RBBB 5%
BNP – Done 363 patients
Average value at admission - 5753
RISK FACTORS GENDER
Total M F
HTN 477 57.26% 221 59.41% 698 58%
DM 466 55.94% 199 53.49% 665 55%
CKD 159 19.09% 56 15.05% 215 18%
SMOKING 490 59% 0 0.00% 490 41%
DIABETES 52%
HYPERTENSION 55%
SMOKING 44%
CHRONIC KIDNEY DIS. 13.5%
RISK FACTORS -- TVM HF Registry.
48%
28%
17%
7%
61%
25%
11%
3%
0%
10%
20%
30%
40%
50%
60%
70%
<65 65-74 75-84 >85
Female
Male
Will Organized Heart Failure programs work?
• Meta-analysis of 30 trials*
HF program Vs routine care
Reduces hospital admissions
Reduces mortality
Reduces costs
• ACC – AHA (2005) given Class I recommendation for
utilization of such programs**
*Holland et.al. heart 2005 91: 899-906.
** ACC AHA Ciculation 2009;119e391-479
Challenges – Budget • Budget – Clearly planned.
• Job description which we want and ICMR do not match.
• Rigid
• We will not be able to initiate the project as planned.
• Project extension ?%$##&!!!
• Quality personnel?
• We appointed male nurses who own a bike – Job
description was clear, - no separate money for data
collection, travel expenses included in salary.
… There is relevance for a Comprehensive HF Management Program
The Program..
Comprehensive Heart Failure Intervention Program
Current Status
ICMR – Supported – Adhoc Research Project. (5/4/1-11-11 NCD2)
56 Lakhs rupees sanctioned FOR 3 years
(1st year funds transferred.)
1. Trivandrum HF registry
2. Comprehensive heart failure intervention program
• TRIVANDRUM HEART FAILURE REGISTRY
• First heart failure registry in the country
• Planning to cover all hospitals in Tvm City and one
rural area in Tvm District (Athiyannoor Panchayat)
This data will form the basis of planning and research of
future heart failure programs in the country
ICMR – CHITRA HEART FAILURE PROGRAM
Comprehensive Heart Failure
Intervention Program.
• Two groups
Routine care Vs
Care under dedicated HF program
Comprehensive Heart Failure Intervention Program
ICMR Study protocol
Heart Failure patients admitted to SCTIMST
(Next one year – 2012-13, n=300)
Newly devised, evidence based
HF intervention program
Mortality,
Readmissions,
Quality of life
Compared to historical controls
admitted in 2011-12 ,n=300
GROUP I
GROUP II
Co-location of HF patients through a dedicated
management protocol
Heart Failure OPD, ward and ICU
Re-orientation of services based on evidence
a. Optimizing medical management
b. Patient follow-up – telephonic and Research Nurse based.
( Developing and testing a model for India,
7 nurses and 2 MSWs allotted in ICMR Project)
ICMR – CHITRA HEART FAILURE PROGRAM
Co-location of HF patients
HEART FAILURE OPD -
Already started functioning – Wednesdays 11 PM
125 patients are in the register and are on regular follow-up
HF – ICU
HF - Ward
We are currently utilizing the existing ward and ICU facilities
Advanced HF management • Cardiology side
Arrhythmia management and re-synchronisation –
Electrophysiology team
RF ablation, ICD, CRT
Coronary re-vascularisation
Bypass graft angioplasty, mitral/aortic valvotomy.
• Cardiac Surgical side
Mitral valve procedures
Mitral valve repair
LV reduction therapies
Dorr procedure, Aneurysm plication
Evaluation of the HF Intervention program
Group I Vs Group II at the end of one year follow-up
IMPACT on..
1. Mortality
2. Hospital admissions
3. Quality of life
Based on the results from the ongoing ICMR study…
To develop a HF management model suitable for India,
logistically feasible and economically viable.
Use the data from the HF registry to plan future strategies.
• Possible to develop a HF management model suitable for India,
logistically feasible and economically viable.
• Use the data from the HF registry to plan future strategies.
POTENTIAL IMPACT OF THE ONGOING ICMR STUDY
Future plans
Center for Comprehensive Heart
Failure Management , SCTIMST
Dedicated “state of the art”
Heart Failure management facility
Dedicated HF management facility
• 1. HF ICU – 10 bedded
(2 cubicles for post- transplant care,
laminar air flow)
• 2. Cardiac Operating rooms for Tx, Specialised procedures
• 2. HF ward – 10 bedded
• 3. HF OPD – 2 physician cubicles
Infusion suite with 2 cots for inotrope/diuretic
infusions on OPD basis.
Cardiac transplant program
No good cardiac transplant network/system in the country.
Aim to develop a cardiac transplant program.
Bridge to transplant
• 1. LV assist devices
• 2. RV assist devices
• 3. LV centrifugal pumps – Impella.
• 4. IABP
• Transplant wait list
• Referral for transplant
Transplant work-up
• Recipients – Transplant list and STATUS LIST will be
prepared and maintained
• List will be ranked based on standard guidelines
pertaining to India
• The HF team will decide the candidate – Necessary
regulations will be followed.
Transplant – Donor flow
Neurosurgery ICU – MCH Tvm
(Evaluation by HF team, donor found suitable, Brain death declaration)
(Matching recipient identified, admitted and prepared in HF ICU)
Donor shifted to SCTIMST, HF ICU/ Cardiology ICU
CAG, Echocardiography, Serology and other work-up
Shifted to CSOT – Transplant
Shifted to CSICU
3RD Day post transplant shifted to HF ICU Cubicles
Post-transplant follow-up
• HF ICU/ward
• Periodic Endomyocardial biopsies, CAG if needed.
• Sinus node function assessment.
• Periodic echocardiography – Tissue Doppler imaging.
• Immunosuppresion protocol.
• Immunosuppressive drug levels - Cyclosporine, Tacrolimus
• DISCHARGE…..
• Weekly – Monthly – Yearly follow-up
Non-invasive imaging…
Echocardiographic evaluation –
development of training programs and
teaching modules
Echo evaluation in HF 1. Assessment of cardiac dys-synchrony
2. Tissue Doppler assessment
3. Stress echocardiography
4. Contrast echocardiography
5. 3D echocardiography
6. Trans-esophageal echocardiography
7. Intra-operative echocardiography
Conducting training programs and developing study materials
and conducting workshops to train physicians
Cardiac Rehabilitation
PALLIATIVE CARE IN HF – Almost non-existent in India
For those not-eligible for transplant and for HF patients
• Exercise programs
• Opioids
• Management of sleep apnoea.
• Counseling
• Anti-arrhythmics to prevent SCD.
• To develop a good rehab program suitable to our country
RESEARCH COMPONENTS
Research components
• 1. Bio-Medical Device development.
VAD is already under development in BMT wing.
This program will augment the development.
New devices may be developed
Centrifugal LV pumps (Impella like)
• 2. Testing of newly evolving therapies.
Cardio-regenerative therapy (stem cell therapy).
Training programs
Training programs which is planned
1. HF Fellowship
One year dedicated course – Post DM
Imaging, transplant work-up and follow-up management
2. HF Nurses
To develop a course to train nurses who can manage HF at the
community level
3. Physician training modules and CMEs.
To develop training and evaluation modules to certify eligible physicians
to enable community level management of HF.
Over view HF patients
HF OPD / Ward / ICU
Optimizing medical management
Detailed evaluation for correctable causes
(Echo – Dysnchrony, CAG – Cath study
Cardiac Resynchronisation
Intracardiac defibrillator
Balloon valvotomy Cardiac Transplant Palliative care
CABG / Valve replacement
• Research
• Training
• Bio-medical device
development
Tvm HF Registry –
Preliminary data analysis
Compared to data from the west, Indian patients are
Younger; have male predominance,
More have CAD and
Very few present with diastolic HF.
In-hospital stay was longer and
mortality was higher, especially among females.
Usage of evidenced based therapy was not very different.
Challenges
• (1) Bringing the physicians together
• Skepticism
• Why should I participate?.
• What is my role?
• Intra-hospital issues – Different units – Only one PI!!
Challenges • (1) Bringing the physicians together
• Define each one’s roles.
• Who will play the lead roles – Clear information.
• Clear plan about the outcome form the study
- Publications – Authorship Criteria
- Presentations in conferences – Who?
• Finances – who will handle? How? Budget should be
discussed in detail
• Staffs – under whom? Which hospital?
Challenges
• (1) Bringing the physicians together
• OUR “SUCCESS”.
• We are a governmental, academic Institution.
• Most of the participating cardiologists – Teachers,
friends.
• Defined the roles, Discussed each and every detail with
all participating physicians from beginning.
• Investigators meeting was the key to success.
• Each one felt they were part of developing the protocol.
Challenges
• (2) Developing the protocol and proforma.
• Suited to our region.
• To identify the most important data to be
captured.
• Discussions and re-do.
•
• Wrong data.
• Missing data.
• False data
•
Challenges –
Data collection
Challenges – Data collection • Training
• Trial run of 5 cases in each center.
• The co-ordinators were personally visiting each center
– So clarifications possible.
• Investigtaor’s brochure
• Verification by PIs.
• Data collection fee given only after submitting a fully
filled proforma.
• Filled by staff nurses who are treating the pts – So
reliable to some extent.
• STILL OUR DATA IS NOT PERFECT.
Challenges –
Loss of interest over time
• First months – 120 cases
• Third month 100 cases.
• Losing interest by the Physicians
• News letter
• Periodic telephonic reminders.
• Rapport with the Data co-ordinators and the Hospital
staff.
Challenges – Too much details
in data
• Echocardiography – Limited data only need to be
captured.
• ECG – SR/AF, LBBB/RBBB, QRS Duration,
Evidence of CAD.
Too many details – will not be analysed, will be difficult to
capture.
Challenges – Staff
• Appointment of staff takes 2-3 months.
• We will not be able to initiate the project as planned.
• Project extension ?%$##&!!!
• Quality personnel?
• We appointed male nurses who own a bike – Job
description was clear, - no separate money for data
collection, travel expenses included in salary.
Challenges – Follow-up • Hospital follow-up, not practical
• Wrong address, Changing mobile numbers, Vanishing
landlines.
• Dis-interest from patient's side, ignorance.
• Mortality – > 15% mortality.
• Difficult to follow-up telephonically after a mortality –
Un-reliable data or no-data.
• Get two tel.numbers
• Call once you get the numbers when patient is still in
hospital and confirm.